High-speed Motor Vehicle Crash Research Articles

Isolated Cecal Rupture after Blunt Abdominal Trauma

Cecal perforation following blunt abdominal trauma is an uncommon and challenging injury. We report a 19-year-old HIV-positive woman who presented with abdominal pain after a high-speed motor vehicle crash. Abdominal exam revealed a seatbelt sign with evidence of peritonitis; Focused Assessment with Sonography for Trauma showed free intraperitoneal fluid. After fluid resuscitation and antibiotics, the patient was taken for urgent laparotomy. Intraoperatively, we discovered hemoperitoneum and an isolated rupture of the cecum. A right hemicolectomy with end-to-end ileo-transverse colon anastomosis was performed. Her only significant postoperative complication was a superficial wound infection. We review the epidemiology of hollow viscus injury in blunt trauma and discuss important considerations in diagnosis and treatment.
 Keywords: Blunt abdominal trauma, Cecal rupture, HIV positive, Hollow viscus

Dual chamber cardiac rupture following blunt thoracic trauma

Introduction: Cardiac rupture following blunt thoracic trauma is rare. When diagnosed, these injuries have a mortality rate approaching 90%. Although there are reports of dual chamber cardiac rupture, there are no documented survivors from this injury. Case Report: A fifty-year-old man presents after high speed motor vehicle crash. On arrival, he was hypotensive with massive right hemothorax. He progressed to asystole but pulse was regained and he went to the operating room. Upon right thoracotomy we encountered a right pericardial laceration and his incision was converted to bilateral thoracotomy (clamshell). He was found to have both right and left atrial rupture. Both injuries were rapidly repaired. The patient survived to discharge neurologically intact. Discussion: Cardiac chamber rupture is rare and often fatal. Survival can occur with dual chamber rupture if swift action is taken and all members of the team work together.

The modified Ravitch approach for the management of severe anterior flail chest with bilateral sternochondral dislocations: a case report

The management of flail chest continues to evolve as scientific evidence and surgical experience accumulates. Flail chest injuries that span the sternum present a rare and complicated injury pattern that can be challenging to manage both medically and surgically. Our patient is a 69-year-old involved in a high-speed motor vehicle crash with respiratory failure secondary to an anterior flail chest. Tomographic examination confirmed a sternal fracture with bilateral sternochondral dislocations and multiple rib fractures. The rib fractures created a lateral flail segment which extended towards the right side. An open Pectus exposure with a right anterolateral extension (modified Ravitch approach) and osteosynthesis plates accomplished stabilization of the chest wall, and contributed to weaning from mechanical ventilation.

Ruptured traumatic ovarian artery pseudoaneurysm in a pregnant patient.

A woman at 36 weeks' gestation was involved in a motor vehicle crash. She required emergency delivery of a healthy infant by cesarean section. She received anticoagulation, despite a splenic injury, for a possible inferior vena cava clot. She re-presented with new retroperitoneal hemorrhage around the juxtarenal aorta. A computed tomography scan suggested a vague contrast blush anterior to the aorta. Arteriography disclosed a right ovarian artery pseudoaneurysm, which was treated with microcoil embolization. The patient has subsequently recovered fully. In major trauma in pregnant patients, ovarian artery pathology needs to be considered in the differential diagnosis of post-traumatic hemorrhage.

Traumatic Spondyloptosis of the Lumbar Spine

Case report. To describe a novel approach to treating traumatic spondyloptosis of the lumbar spine. Traumatic spondyloptosis of the lumbar spine is a relatively uncommon injury because it requires a significantly large amount of energy to occur. Reduction of these fracture dislocations in the operating room may be difficult through a solely open approach because it usually requires a significant degree of bone removal and spinal manipulation with instrumentation. In this case report, the authors present a unique method of closed reduction followed by open fixation of a traumatic fracture dislocation of the lumbar spine. The patient in this study experienced a traumatic spondyloptosis of L3 on L4 from a high-speed motor vehicle crash in which he was ejected from the vehicle. The patient had experienced nearly complete anterior/posterior translocation of L3 on L4 and had avulsed the anterior superior aspect of the L4 vertebral body. On presentation to the trauma center, he was ASIA (American Spinal Injury Association) B; he had patchy sensory preservation in his left lower extremity. The surgical goal was to relocate his spinal fracture and rigidly fix it with a pedicle screw and rod construct. Under fluoroscopic guidance and with the patient under general anesthesia, we performed a closed reduction of the spinal fracture using lumbar hyperextension and full torso longitudinal traction. We were able to reduce the fracture almost completely using this technique. After open internal fixation of the patient's fracture with a rod-pedicle screw construct, we reduced the patient's fracture to a grade II spondylolisthesis, effectively. The patient went on to recover a small amount of neurological function after the procedure. The authors think that this is an effective method for reduction of these severe fractures.

LETTER TO THE EDITOR Spinal Manipulation is Not an Emerging Risk Factor for Stroke Nor is it Major Head/Neck Trauma. Don't Just Read the Abstract!

Dear Editor, We read with interest the article by Micheli et al. [1] describing the emerging risk factors for cervical artery dissection. In their abstract, the authors’ state, “Other known risks factors for CAD are major head/neck trauma like chiropractic maneuver, coughing or hyperextension injury associated to car.” We would like to address two points in this letter: 1) the current best-evidence indicates no causal relationship between spinal manipulation (‘chiropractic maneuver’ in the paper) and vertebrobasilar artery (VBA) stroke, and 2) spinal manipulation or ‘chiropractic maneuvers’ are not major head/neck trauma as suggested in abstract of this article. First, evidence is mounting that the association between spinal manipulation and stroke is coincidental rather than causal and reflects the natural history of the disorder [2]. The largest population-based study to date was conducted by Cassidy et al. [3] and included all vertebrobasilar artery (VBA) strokes in Ontario, Canada over a period of 9 years. The authors found no evidence of excess risk (i.e. no risk) of VBA stroke associated with chiropractic care [3]. Interestingly there was an association between stroke and visits to both chiropractic and medical physicians but the association was the same for each type of provider [3]. The prevailing hypothesis is that patients with vertebral artery dissections often have initial symptoms that cause them to seek care from a chiropractic or medical physician and the stroke is independent of their visit [2-4]. This population-based study (Cassidy et al., 2008) provides higher quality evidence than previous case reports, case series, and physician surveys frequently referenced when discussing spinal manipulation in this context [2]. If anything, the latest scientific evidence questions whether spinal manipulation is a risk factor at all for cervical artery dissection. In contrast to the title of the Micheli et al. (2010) paper, chiropractic spinal manipulations may very well be a demerging risk factor for stroke since there may not be any risk. Secondly, spinal manipulation or ‘chiropractic maneuver’ (assumed to be cervical spine manipulation) is not major head/neck trauma as inferred in the abstract. The body of the Micheli et al. paper [1] even mentions that spinal manipulations are not considered major trauma, so the abstract is clearly inconsistent with the findings and should be corrected. The evidence, albeit limited to date, suggests that spinal manipulative treatments produce stretches of the vertebral artery that are much smaller than those that are produced during normal everyday movements, and thus they appear harmless [5]. Major trauma is usually associated with high-energy mechanisms of injury and results in serious visceral injury or spinal motion unit injury such as fracture or dislocation [6]. High-energy mechanisms of cervical spine injury have been described as those involving a high-speed motor vehicle crash (greater than 50 km/h), pedestrian being struck by car or a fall from greater than 3 m [7]. Clearly, spinal manipulations delivered by licensed chiropractors do not fulfill the criteria for major trauma and should not be considered major trauma. In addition, contrary to what was stated in the Micheli et al. [1] paper, it is also equally unlikely that most episodes of coughing fulfill the criteria for major trauma.

Bilateral internal carotid and vertebral artery dissection after a horse-riding injury

Blunt cerebrovascular injuries, defined as blunt injuries to the internal carotid or vertebral arteries, are uncommon and usually occur in victims of high-speed deceleration motor vehicle crashes. A blunt cerebrovascular injury after an equestrian accident is an extremely unusual presentation. In recent years, advances in screening and treatment with pharmacologic anticoagulation before the onset of neurologic symptoms have improved outcomes for these patients. Endovascular stenting and embolization, although unproven, offer a new potential approach for these complex injuries. We present a unique case of four-vessel blunt cerebrovascular injuries after a horse-riding injury that required multidisciplinary management.

Thoracic Spine Injury after a High-Speed Motor Vehicle Crash

In late October, a hospital-based flight team was activated at 9:30 pm for an approximately 30-year-old man involved in a high-speed motor vehicle crash into a tree. Per emergency medical services (EMS) documentation, flight service was requested for advanced airway management and rapid transport of the patient to a Level 1 trauma center. Ground transport was estimated at 60+ minutes, whereas actual flight time was less than 15 minutes. On the crew's arrival at the designated landing zone, they were escorted to an ambulance where a 100-kg man was immobilized on a stretcher. Because the landing area was at a remote location, the flight team did not witness the scene; however, the ground paramedic reported that the patient was the single-occupant driver of a small sedan. Given the extent of damage to the front and passenger side of the vehicle, it was determined that the patient was driving at a high rate of speed when he struck the tree. He required approximately 20 to 25 minutes of extrication. An empty bottle of zolpidem (Ambien) was found on the floor of the vehicle; the 30-day prescription had been filled approximately a week before the accident occurred.

Traumatic Diaphragmatic Rupture with Intrathoracic Liver Herniation

A 24-year-old male seat-belted driver involved in a high-speed motor vehicle crash was taken to the operating room for repair of a partial aortic transection. After resolution of the right hemopneumothorax, an elevated right hemidiaphragm was seen on a chest radiograph.

Is Chest X-Ray an Adequate Screening Tool for the Diagnosis of Blunt Thoracic Aortic Injury?

Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI. All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI. In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001. Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

Adolescent pneumopericardium and pneumomediastinum after motor vehicle crash and ejection

A 15 year old male was an unrestrained passenger in a high speed motor vehicle crash followed by ejection. The patient was noted to have evidence of bilateral pneumothorax upon arrival in the Emergency Department. Bilateral chest tubes were placed under sterile conditions; however, the left pneumothorax remained, and a second left chest tube was placed. Repeat chest radiographs revealed extensive subcutaneous emphysema, pneumomediastinum, and pneumopericardium. Needle aspiration of the pericardium returned significant quantities of air, an immediate improvement in blood pressures followed. An 18-gauge triple lumen catheter was placed into the pericardial space for additional withdrawal of air via syringe. Mechanisms have been proposed to explain the development of tension pneumopericardium after chest trauma. Early diagnosis is crucial, and may be found on initial chest radiographs. Computed tomography is also an effective method for evaluating the presence of air in the pericardial space and may assist in establishing the diagnosis. Tension pneumopericardium requires immediate recognition and decompression to prevent cardiac tamponade with a fatal circulation collapse, an entity that is as serious as the tamponade resulting from hemopericardium. Traumatic pneumopericardium is rare, but can be a complicated finding associated with high-speed blunt chest trauma. Patients with evidence of pneumopericardium should be closely monitored, particularly those supported by positive pressure ventilation.

Tension pneumopericardium and pneumothorax during spontaneous ventilation

Tension pneumopericardium and pneumothorax during spontaneous ventilation

Delayed manifestation of abdominal aortic stenosis in a child presenting 10 years after blunt abdominal trauma

We report the case of a 13-year-old boy who, at 3 years of age, was a rear seat-restrained passenger in a high-speed motor vehicle crash necessitating segmental small-bowel resection. The patient remained well for 10 years; then he began to have exercise-induced fatigue in his lower extremities. Routine physical examination revealed a bruit and thrill in the mid abdomen and diminished femoral pulses. Aortic stenosis was diagnosed and treated surgically. We discuss the pathophysiology of the lesion and review the literature. This is the first report of abdominal aortic stenosis 10 years after blunt abdominal trauma in a child.

Pattern of visceral injuries following blunt abdominal trauma in motor vehicular accidents.

To determine the frequency of various visceral injuries following, high-speed motor vehicle crashes with special reference to frequency of liver injuries, severity and complications. A descriptive study. Surgical Unit III, Jinnah Hospital, Lahore, from August 1999 to February 2002. The study included 100 consecutive patients of blunt abdominal trauma. Patients of either gender and age above 12 and below 70 were included in this study. Purposive non-probability sampling was done. Injuries were identified, graded and managed accordingly. The data was then entered into SPSS and descriptive statistical tests were applied. Liver was the most common organ injured (35%), followed by spleen (32 %) and small gut (30 %). In 23 patients, liver was the only organ injured. Most of the liver injuries fell under grade I (42.8%) followed by grade II (28.35%) and grade III (22.85%) and were treated by suture hepatorrhaphy alone in 71.42% cases. The operated cases were mostly complicated by wound infection (33.76%). Overall mortality remained high (12%) and was related to a combination of delays in arriving at a diagnosis due to non-availability of CT scan and routine use of peritoneal lavage. Liver is the most commonly affected organ in high speed motor vehicle crashes that is reliably treated by suture hepatorrhaphy. The rate of postoperative infection and morbidity is high.

Electrocardiographic ST-segment elevation in the trauma patient: acute myocardial infarction vs myocardial contusion

The diagnosis of myocardial contusion in the setting of blunt trauma engenders much discussion and controversy—partly because of the lack of a gold standard for its identification other than histologic findings at autopsy. Furthermore, blunt cardiac trauma represents a spectrum of disorders ranging from transient electrocardiographic change to sudden death from myocardial rupture; hence, no single terminology exists to define such a wide range of scenarios. Here, we present 2 cases of electrocardiographic ST-segment elevation after high-speed motor vehicle crashes resulting in numerous injuries, including blunt chest trauma. Both patients demonstrated electrocardiographic ST-segment elevation, resulting from myocardial contusion and acute myocardial infarction.

Sex differences in injury severity and outcome measures after traumatic brain injury

Slewa-Younan S, Green AM, Baguley IJ, Gurka JA, Marosszeky JE. Sex differences in injury severity and outcome measures after traumatic brain injury. Arch Phys Med Rehabil 2004;85:376–9. Objective To investigate the effect of a patient’s sex on various measures of injury severity and outcome after rehabilitation in a matched sample of patients with traumatic brain injury (TBI). Design Retrospective data were retrieved from a database that contains information routinely collected on all patients admitted for inpatient rehabilitation. Setting Inpatient rehabilitation unit of major teaching hospital in Australia. Participants Fifty-four women with TBI after a motor vehicle crash (MVC) were identified from the Brain Injury Rehabilitation Database. An equal number of men were then matched for age and years of education. All subjects met the study admission criteria of having being involved in a high-speed MVC. Exclusion criteria included history of a previous head injury, chronic amnesia, psychiatric disturbance, and significant alcohol and/or substance abuse. Interventions Not applicable. Main outcome measures Differences, by sex, in patient scores on measures of injury severity and outcome after TBI. Results Men had significantly greater levels of injury severity as indicated by the Glasgow Coma Scale scores ( U=994.0, P=.002) and length of posttraumatic amnesia ( U=880.0, P=.016) when compared with women. No significant sex differences existed in the outcome measures or in injuries not associated with the central nervous system. Conclusions Few investigations exist on the effect of patient sex on measures of injury severity and outcome after a TBI. In the present study, men’s levels of injury severity were greater than women’s despite the same admission criteria (high-speed MVC) being applied to both sexes.

Seatbelt Injury Causing Perforation of the Cervical Esophagus: A Case Report and Review of the Literature

Blunt trauma to the head and neck is a rare cause of cervical esophageal perforation. We report a cervical esophageal perforation caused by compression by a shoulder-harness seatbelt during a high-speed motor vehicle crash. We are not aware of a similar case in the trauma literature.

Fluid-filled bowel mimicking hemoperitoneum: a false-positive finding during sonographic evaluation for trauma

This case report describes a patient who presented to the Emergency Department (ED) after a high-speed motor vehicle crash (MVC), whose initial ultrasound examination was interpreted as being positive for fluid in Morison’s pouch. Subsequent ultrasound examinations and computed tomography scans further delineated this finding to be fluid-filled bowel juxtaposed between the liver and right kidney. With greater implementation of ED ultrasound, it is important to identify entities that cause false-positive and false-negative examinations.

Tracheobronchial injuries

A 27-year-old man, formerly in good health, arrived at the local trauma center after a high-speed rollover motor vehicle crash. He was in frank shock, with bilateral tension pneumothoraces. The team intubated him immediately and placed bilateral chest tubes. A computed tomography scan of the head showed severe traumatic brain injury with diffuse axonal injury and intraventricular bleeding. Additional injuries included bilateral full-thickness burns to his lower extremities, multiple facial fractures, multiple rib fractures, and pulmonary contusion.

Blunt traumatic injuries

Dr. Gary Zimmer: Today’s case is that of a 44-year-old woman who was involved in a high-speed motor vehicle crash. She was a restrained driver traveling at approximately 70 miles per hour when she lost control and struck an immovable object. There was transient loss of consciousness and she was transported by ground Emergency Medical Services (EMS) to the local community hospital. She was reported to be hemodynamically stable, complaining of right hip pain and chest pain. Her two children were rear-seat, restrained passengers, both of whom were critically injured. Her past medical history was significant for a history of seizure disorder. Her last seizure was many years ago and she was not taking any medications. She had no history of substance abuse or depression. Are there any questions?